A Practical Guide on
Physiotherapy Assessment
for Physiotherapy Students
A Practical Guide on
Physiotherapy Assessment
for Physiotherapy Students
Gopal Nambi S MPT PhD MBA (USA)
Assistant Professor Department of Physical Therapy and Health Rehabilitation College of Applied Medical Sciences Prince Sattam Bin Abdulaziz University Al-Kharj, Kingdom of Saudi Arabia
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[email protected] A Practical Guide on Physiotherapy Assessment for Physiotherapy Students First Edition: 2017 ISBN: 978-93-5270-064-6 Printed at Repro India Limited
Dedicated to My loving Aunt Late Pankajam K
Preface
As an academician, I noticed that there are many textbooks written on various treatment modalities in physiotherapy and the theories behind them, but the in-depth assessment of various specialities is still uncovered. Teachers and students had to refer to multiple books as no single book covered the practical assessment in detail. It led me to create a handbook A Practical Guide on Physiotherapy Assessment for Physiotherapy Students that did not fit into the mould offered by the existing textbooks. The book provides precise and concise explanation of all the content which is necessary for a strong foundation for practical and clinical assessments. At the same time, the contents of the book compiles and covers the practical curriculum of assessment in various universities. This book integrates different practical application procedures in physiotherapy which are often found split in many books. Hence, I hope to provide a better understanding in the field of practical physiotherapy. This book was motivated by the desire to simplify the practical and clinical aspects of assessment in physiotherapy especially for the undergraduate and postgraduate physiotherapy students and clinical therapists working in the clinical set up. This book is referred from various national and international books to serve a number of objectives. One of the primary objectives is to define the different types of assessments commonly used in the field of health sector which provides the understanding of selection and application of different types of assessments in the field of physiotherapy. With speciality assessment becoming increasingly important in a much wider ranges in the field of physiotherapy, therefore, the secondary objective is to discriminate the different speciality assessment (Orthopaedics, Sports, Neurology, Paediatrics, Cardio and Pulmonary, etc.) methods in the field of physiotherapy which provides the strong foundation in the speciality assessment. Finally, a more pervasive objective is to expose all students and clinicians to not only use the assessment methods, but also to provide intellectual rich contents. I believe that, as times go on, all students and clinicians will take the benefit of this practical guide in a fruitful manner. As this book is still in its infancy stage, your feedback will be appreciated. Gopal Nambi S
Acknowledgements
This work would not have been possible without the support of Dr Hamdan Ali Alshehri, Dean, College of Applied Medical Sciences, and Dr Fathy Elshazly, Head, Department of Physical Therapy, Prince Sattam Bin Abdulaziz University, Kingdom of Saudi Arabia. I am grateful to my friend Dr Walid Kamal and all the faculties and students those with whom I have had the pleasure to work with at CU Shah Physiotherapy College, Surendranagar, Gujarat, India. I would like to express my special gratitude to my mentor and guide Dr MM Prabhakar, Medical Superintendent, Civil Hospital, Ahmedabad, Gujarat, whose stimulating suggestions and encouragement had always pushed me to do my best. I would like to thank my mother Sujatha and brothers, whose love and blessings are with me in whatever I pursue. I also wish to thank my supportive wife Dr Dipika and my son Shaan, who provide me with unending inspiration.
Contents
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Introduction to Assessment Musculoskeletal Assessment Orthosis Prescription Assessment Prosthesis Prescription Assessment Sports Injury Assessment Sports Fitness Assessment Neurological Assessment Paediatric Assessment Cardiac Assessment Peripheral Vascular Disease Assessment Respiratory Assessment Intensive Care Unit Assessment Geriatric Assessment
Annexures 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
General Medical History—Questionnaire Type of Pain History—Questionnaire Assessment of Range of Motion Assessment of End Feel Assessment of Capsular Pattern of Restriction Assessment of Muscle Strength Assessment of Muscle Length Assessment of Sensation Assessment of Reflex Assessment of Non-equilibrium Assessment of Equilibrium
1 6 15 23 29 37 43 52 59 66 73 84 96
105–136 105 106 107 110 113 114 116 117 118 119 120
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A Practical Guide on Physiotherapy Assessment for Physiotherapy Students
12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
Assessment of Dermatome Assessment of Myotome Assessment of Posture Assessment of Gait Assessment of Functional Activity Assessment of Environment Assessment of Cranial Nerves Assessment of Disease Specific Scale Assessment of Primitive Reflex Assessment of Birth History Assessment of Milestone Assessment of Paediatric Muscle Strength Assessment of Nutritional Status
121 122 124 125 127 129 130 131 132 133 134 135 136
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C H A P TE R
Introduction to Assessment There is No Short Road to Knowledge
“Diagnosis arises from the examination and evaluation and represents the outcome of a process of clinical reasoning. This may be expressed in term of movement dysfunction or may encompass categories of impairments, functional limitations, abilities/ disabilities or syndromes.” WCPT (1999, P.7)
CLINICAL DECISION MAKING A thorough understanding of the patient and his/her disorder is a complex process which involves a series of interrelated steps which help the physical therapist to plan an effective treatment compatible with the needs of the patient and the goals of the health care team. These steps include: 1. Assessment of the patient. 2. Identifying the problem. 3. Determining the diagnosis. 4. Determining the prognosis and plan of care. 5. Implementing the plan of care. 6. Reassessment of the patient and evaluating the treatment outcome. Adequate knowledge and experience, cognition process strategies, communication and teaching skills are important components of skilled decision making. Also a good communication amongst the rehabilitation team members and effective documentation is a must for timely reimbursement of the services.
PROBLEM-ORIENTED MEDICAL RECORD (POMR) Originally developed by Weed, which is used by many therapists and institutions. Divides the treatment process in four phases. Phase-1: Includes a detailed physical examination, laboratory and other tests and their results. Phase-2: Interpreting the database to identify the specific problem. Phase-3: Choosing a treatment plan for each of the problem also includes making of an evaluative progress note for each problem. Phase-4: Assessment of the effectiveness of each of the plan and making necessary changes as the treatment progress.
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A Practical Guide on Physiotherapy Assessment for Physiotherapy Students
SOAP Format
Subjective finding Objective finding Assessment Planning of treatment. Progress report is written in the subjective, objective, assessment and plan (SOAP) format. Subjective findings are what the patient or his/ her family report. Objective findings are what the therapist observes measures or tests. Assessment is correlating the subjective and objective findings to formulate long and short-term goals and plan is fixing the interventions. The POMR highlights the relationship of the database to the treatment plan thus makes the specific problem of the patient to become the central focus of planning. To store the large amount of data computerized POMR is available.
ASSESSMENT AND EVALUATION Assessment is the means of evaluating everything done during clinical decision making process (clinical reasoning). The effectiveness of a treatment is assessed by comparing the effects of the selected and processed techniques on the patient’s signs and symptoms. To complete proper assessment a thorough systemic examination is required. A correct diagnosis depends on knowledge of functional anatomy, accurate patient history, diligent observation and thorough examination.
ASSESSMENT OF THE PATIENT It is believed that 80% of the information needed to identify the cause of the symptoms is given by the patient himself during history taking, thus making interviewing a very important skill for every physiotherapist to learn.
INTERVIEWING TECHNIQUES 1. 2. 3. 4.
Open-ended questions: Answers to these are in more than one word. Closed-ended questions: Answer is either ‘yes’ or ‘No’ Funnel technique or Funnel sequence: Starts with open-ended question and ends with close-ended questions. Paraphrasing technique: Synthesizing and integrating the information obtained during questioning. This helps in identifying the patient’s problems. The resources available for proper intervention consist of three components: 1. Patient history 2. System review 3. Tests and measures. 1. Patient history: History can be obtained from the patient, family or caregiver. Information obtained should contain the patient’s primary complaint, history of present illness, significant medical condition that affected them in the past, lifestyle practices and habits. The therapist should listen carefully to the patient and observe for physical manifestations that reveal the emotional, state of the patient (e.g. Slumped body posture, poor eye contact, etc.). Interview is also an effective tool for establishing rapport for effective communication and mutual trust which in turn are vital for the success of the rehabilitation program. 2. System review: It involves a brief examination of the entire body, followed by the detailed examination of the area of interest. This allows the therapist to decide if the patient’s problems can be treated by him or if he should be referred to a specialist for significant medical condition.
Introduction to Assessment 3. Tests and measures: These are definitive assessment tools used to determine the degree of dysfunction (e.g. Range of motion, oxygen consumption, manual muscle test, etc.). Adequate training and skill are required to perform these tests to ensure the validity and reliability or it could result in inaccurate data leading to an inappropriate treatment plan. The therapist should review the patient’s problem and choose for the appropriate test, also he/she should resist the tendency to gather extraneous data which might not only confuse the diagnosis but also increase the cost of care. Only in case where the initial data obtained are inconsistent should addition or specialized test be indicated.
PURPOSE OF ASSESSMENT The purpose of assessment is to clearly understand the patient’s problem. It serves several purposes. 1. Physiotherapy diagnosis. 2. Definition of physiotherapy objectives. 3. Determining treatment intervention. 4. Defining the parameters to monitor the effects of therapy. 5. Better recognize common disorder. 6. Impose overall health and functional outcomes. 7. Reduce vulnerability to subsequent illness. 8. Provide better quality of life.
FORMS OF ASSESSMENT Different forms of assessment have described (Maitland et al 2001) and summarized as follows: 1. Assessment during initial consultation includes the welcoming and information phase. 2. Reassessment in various phases of each treatment session. 3. Assessment during the application of treatment intervention. 4. Retrospective assessment and prospective assessments to monitor the overall process. 5. Final analytical assessment including the parting phases in which measures are undertaken to enhance long tem.
Assessment at Initial Examination At the first session the therapist has to gather information about the patient and accordingly draft a treatment plan. This information includes the following data. Biomedical Psychological Social Cultural The key is to develop a clear, disciplined procedure of examination and planning. Improvisations are made to adapt the procedures for special needs of patients. The following algorithm of information, procedures, reflections and planning are suggested for the first session Algorithm of first session. Within the first session the physiotherapist should collect information regarding: Causes and contributing factors for the condition. Treatment goals and suitable interventions. Activity involving the patient in the treatment process. Any precautions or contraindications in regards to examination or treatment procedure.
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